Putting the health-care bill into perspective

This column originally appeared in the Sunday business section. Also, I'm off today for Martin Luther King Jr. Day. Regular blogging resumes tomorrow.

No matter what the players involved in the health-care reform fight want for the bill, they're all united in one respect: They want you to believe this is the biggest thing in the world. Republicans want you to believe it's a dangerous proposal that will wreck a sixth of the economy. Democrats want you to believe it's a marvelous bill that will fix the health-care system. The news media frequently take both claims at face value.

It's time for some real talk on health-care reform. By the standards of what Congress generally does in a year, this bill is very big. But by the standards of the health-care system, it's not that big at all. It goes two-thirds of the way on covering the uninsured. It makes a courageous, but insufficient, start on cost control. This is the beginning, not the end, of reform.

Let's begin by breaking down the numbers. The $900 billion price tag is repeated with the regularity of a rooster's crow. That's a shame, as the number is, somewhat impressively, misleading in both directions.

On the one hand, that $900 billion is stretched over 10 years. But people don't think in 10-year increments. They don't pay taxes once a decade. Put more simply, the bill will cost an average of $90 billion a year.

But that number is meaningless without context. Ninety billion is a lot more than you probably paid for, say, your house. But is it a lot of money in the context of national health-care spending? Not really. In 2008, we spent $2.3 trillion on health care. Ninety billion is about 4 percent of that. In other words, a drop in the bucket.

On the other hand, the bill wouldn't really kick in until 2014. There are two reasons for this. First, it takes a bit of time to set it up. Second, it's an effort to make the price tag, which is measured over 10 years, look lower than the true cost. To get a more accurate annual figure, look at a year in which the bill is fully operational. In, say, 2016, the bill's spending will be about $150 billion. According to the Center for Medicare and Medicaid Services, total health-care spending that year will be about $3.7 trillion. The bill will account for less than 4 percent of it.

So that's really what we're talking about here -- a health-care expansion that's a slight fraction of overall spending. Let's go even further: It's an expansion that most people won't notice in 10 years. According to the Congressional Budget Office, the Senate bill will change the insurance of about 40 million people by 2019, about 30 million of whom would have been uninsured. The other 10 million will come from the employer or individual markets in search of more affordable options. About 8 percent of the country will still be uninsured, though that falls to 6 percent if you exclude illegal immigrants. Ninety percent of Americans will be exactly where they'd otherwise be.

That accounts for the spending side of the bill. What about the cost control?

It's the same story, but more so. Although the bill solves most of the coverage problem, it accounts for a mere fraction of the cost problem. A new report by the centrist policy group Third Way estimates that the legislation will save more than $800 billion over the next 15 years. Again, that's a big number. Quite a bit more than my car cost, and I thought my car cost a lot of money. But the savings amounts to no more than a rounding error given the tens of trillions of dollars we're going to spend over that period.

Importantly, though, it's a rounding error in the right direction. The bill is thick with efforts to move toward cost control, if not efforts to actually impose cost controls. The excise tax, the Medicare Commission, the pilot programs to change how hospitals are paid and most of the other proposals are designed to bear fruit in the future. The excise tax -- which slaps a fee on high-cost plans in order to give a competitive advantage to those that hold costs down more effectively -- initially applies to very few plans but would hit more as premium costs rise. The payment reforms have to pay off as pilot programs before being considered for Medicare-wide -- much less systemwide -- use.

Some pundits respond to all this by flippantly demanding that the White House build more cost control into the bill. Putting aside the fact that this is Congress's joint, not the administration's, consider the difficulty of just one of the cost controls: The excise tax, which is too small as it is (and which shrank slightly after unions and liberals rebelled), remains only because the administration fought tooth and nail for it. Other efforts at cost control -- from a public option that could use Medicare rates to a cap on the employer tax exclusion to the global budgets that the Clinton administration proposed in the '90s -- were unceremoniously dumped from the bill.

But some will have to come back, eventually. And it will be much harder than just cutting costs one year. We tend to think in terms of spending cuts, which are painful but simple. We're going to need to think in terms of spending reforms. The problem with health-care spending is not that we spent $2.3 trillion in 2008. It's that that number has been growing by 7 percent annually. It's the rate of increase, and not the level of spending, that we need to change.

Consider again the $2.3 trillion we spent in 2008. Given the current rate of growth, in 2028, we'll spend $8.9 trillion on health care. Imagine, however, that we got really serious about cost control and cut $200 billion next year. If costs were to grow at the same rate, we'd still be spending $8.1 trillion in 20 years. Imagine, then, that we didn't cut a dollar -- but got cost growth down to 5 percent (which is still faster than wage or GDP growth). In that case, that $2.3 trillion would only be $6.1 trillion in 2028. That's actually manageable.

But changing the growth of the health-care system is a lot harder than just cutting a few dollars here or there. It requires us to change how doctors practice medicine, or how much medicine people buy or how much they need -- or maybe all three. We're doing a lot on health-care reform this year, but we're not doing that much. And we shouldn't fool ourselves into thinking otherwise. We'll be back at this again, and soon.

"We're doing a lot on health-care reform this year, but we're not doing that much. And we shouldn't fool ourselves into thinking otherwise. We'll be back at this again, and soon."

Sorry Ezra to say this but I would say we may be back to it to start all over again considering how the politics is going! With every poll showing now that MA race going to GOP way, I am not so sure whether Dems will keep it. Legal wrangling of whether Kirk will add Dem vote when the election is done (no matter what the result is); undermines passing anything now by the Senate.

I think Lefty bloggers have 'failed' to point the dangers of politics triumphing and potentially eating the Policy here.

The unique thing about this blog was Politics was followed along with details of Policy. But when 'attention' to politics stay behind, we land up into one more detailed policy jargon, it becomes a policy journal.

something beautiful for Martin Luther King day.
a tribute also, to an inspiring and magnificent woman who helped pave the way on the road of difficulty.
women like lena horne must not be forgotten.
http://www.youtube.com/watch?v=MvlP6EIOkNQ

Again I see the conflation of the words "health care" and "insurance coverage". In my view the most promising and revolutionary changes in health care are being done by Kaiser Permanente, where medical providers are on a payroll, where care is prevention front loaded, where drugs are purchased in quantity, where procedures are evidence based, and where the primary care physician is the key player and where all records are digitalized, and communications with providers, including the primary care physician are done electronically and expeditiously. I am fortunate enough to be a Kaiser patient and to be well served by their excellent system.

Yesterday the President said the health bill "will be a victory for dignity and decency, for our common humanity." Where is the dignity and decency in a bill that fails to accomplish the primary goal of reform, of coverage for all the uninsured, that required bribery, extortion, racketeering and placation of speical groups which negatively impact a greater population of Americans? If it is filled with such dignity and decency why are we not seeing it unfold on C-Span? In the dark of night and with the speed of light members of Congress continue to be indignant and indecent in their actions to provide real reform for Americans.

It is fundamentally dishonest to describe the excise tax as "slaps a fee on high-cost plans in order to give a competitive advantage to those that hold costs down more effectively" when the actual effect - as shown by two surveys - will be that employers will simply dump more of the cost on the employees. Yes, it will bring *premiums* down, for the employer. But it does not bring the *costs* down - it just changes who pays those costs.

And, as those same surveys have shown, it's a pipe dream to think that workers will see higher wages from their employer's cost savings. Something like 85% of the employers have said that they'll simply keep the money. And it won't even reduce the deficit. The deficit-reducing projections from the excise tax almost entirely depend on those pipe-dream "higher wages." I have decided to start calling it the "Tiggypoop" tax - (Tax Good Insurance Plans Out Of Existence Plan).

It is so much fun to tell people that $900 billion is not a lot of money (in the context of US health care spending over 10 years). :)

Though most media coverage of health care reform is shoddy, it is refreshing that we have a few journalists like Ezra Klein and Uwe E Reinhardt who cover the issue really, really well. I just wish the rest of the media and the public would pay more attention to them.

Reasonable column, I think a point that I've made in the past-- market forces will be critical to get real cost control, the government simply can't do it on their own. So while efforts to hold onto the excise tax or Medicare Commission are laudable from a political perspective, they aren't likely to make much of a difference from a policy perspective. Its why Wyden-Bennett was simply a better approach to health care reform. Forcing people to make benefit/cost decisions, rather than the government, will ultimately be the way costs are controlled. Whether we have to go through single-payer and the resulting bankruptcy of our country first, remains to be decided. I'd hope that the current reform effort would get folks like yourself to consider the foolishness with making government efforts the CENTER of reform efforts, rather than focusing on how the government allows the market to work without harming people in the process. The former simply isn't politically feasible.

I would quibble with one important thing:

"We'll be back at this again, and soon."

I'd question the "soon" part. There is a "doc fix" to deal with in the short-run, but assuming that ends up being a $250 billion add-on with no meaningful physician practice reform, its hard to see the next point this gets addressed. Towards the end of an Obama second term, at the earliest? What exactly would politically force a discussion before that? There doesn't seem to be much political reward in attacking costs-- not until annual debt starts impacting people in a tangible way. I'd love to hear a political scenario that forces a discussion before that-- particularly after the bruising fight this round of reform has been-- all expected-- which is why true cost control, focusing less on government-driven efforts and more on making the market effective-- a la Wyden-Bennett-- was always the better approach this time around.

Why don't they work on tort reform? If it's truly only 1% of healthcare costs, why don't they address this problem quickly? Since 1% is easy to fix. Doesn't that make sense. Oh wait, most of the members of Congress at lawyers and would never do anything to harm the trial attorney's potential to earn money.

You fail the basics of journalism 101 yet again Ezra. I continue to be stunned and dismayed at your utter lack of economic sense. Where does the Post find you guys?

This bill over time will completely gut the federal government. Any rational person who has studied the cost trajectories of SS and Medicare plainly see this. In time, it will lead to massive rationing in the system and a significant decline in care for all citizens. Additionally, our nation’s preeminence in medical discovery will wane severely over time causing a further reduction in the quality of our healthcare. There are so many other ways to shore up the system and make it better for everyone. You continue to shrill the Obama option which guts the system that currently provides healthcare to 90% of the country. If this weren’t such a historically important issue for the country, I’d laugh at your ideological drivel. But the stakes are too large here and I’m left angry that you’ve got such a large forum to spew your inane, juvenile thoughts.

I think you're missing the bigger points, Ezra. On the spending side, the cost estimates from CBO are interesting (and not too shocking), but the actual reports from CBO are littered with red flags - footnotes that state that they are compelled to "score" based on the assumptions provided them, but that the assumptions are far from certain, and really, really politically unlikely.

Aside from the cost estimates, the bigger concern is the establishing of a new Federal entitlement, which will affect the large majority of Americans. It will make the entitlement bombs of Social Security and Medicare look easy in comparison.

On the cost control side, you seem to start from the assumption that all cost control must be organized and directed from Washington. Given this assumption, I suppose that the Democrat proposals have some good ideas. However, the only cost control that will ultimately be palatable will be on that gives more control, not less, to patients/customers/taxpayers. Both the House and Senate bills prevent anything in this direction by mandating that all insurance must cover all medical services, with low out-of-pocket expenses. This would end the high-deductible, low-premium policies that are beginning to become popular.

Ultimately, controlling costs involves someone deciding not to pay for questionable or unaffordable services. We've had several models over the past 20 years or so to pick the "bad guy". Insurance companies tried to say No, and were savaged, politically and economically. They've given up. They tried to enlist doctors to say No, by tying doctors' reimbursements to referral rates; both the doctors and the insurance companies/HMOs were savaged, and they've given up. Government bureaucrats will likewise be savaged, and will eventually try to give up (but legislative budgeting may force them into this role anyway). If patients are ALLOWED to self-insure for most of their spending, with insurance to cover large and unexpected costs, then patients will have an incentive to question the costs, benefits, and risks of proposed treatments, and sometimes say No on their own account. If I were the type to impose my solution on everyone, I'd mandate this type of insurance. Since I'm not that type, I hold out hope that people might remain free to try it if they're willing. And that the issue won't be further clouded by massive subsidies that continue to hide the costs of the current system.

If you spread that ninety billion health insurance reform pricetag over 300 million Americans, it's not that much at all, per person.

Sadly, I think this big bill is done. I say sadly because a bill that would give insurance to 30 million Americans while also reducing the deficit should be a good thing.

Health care should not be politicized, but it was so we'll be stuck with this terrible system we currently have, where private companies decide whether to pay our health bills and, in the end, in some cases, decide whether we live or die, in light of their corporate profits.

High on sonority, low on content as my old english prof would say. The article is RIFE w/ inaccuracies, falacies, misunderstanding of the bill(s) and perhaps, lies. Who knows.

1. The $900 bil/yr for 1st 10 yrs is accounting gibberish: The 10 yrs of fees/taxes pay for 6-7 yrs of costs. In addition, 1st 10 yrs INCLUDES premiums for CLASS svcs which won't start for 5-10 yrs depending on demographics. Funding DEPENDS on $583 BILLION in Medicare CUTS and a 21% REDUCTION in Medicare pmt rates to MD's and hosps. Billions in "savings" are "generated" by forcing states to EAT the costs of Medicaid costs (unless you're Neb and FLA among others). Finally CBO states that costs "estimates" for the 2nd 10 yrs are MEANINGLESS (their word).
2. Nothing will change: UNLESS ANY detail of my private plan changes - i.e. deductibles, co-pays, coverage details - THEN I MUST go to an exchange. Private co's are grandfathered for 5 years then MUST provide coverage from the exchange.
3. This is the MOST corrupt political action I've seen in my life (60 yrs) w/ the possible exception of the Gulf of Tonkin Resolution. Senators have been BRIBED to vote for their party's OWN plan. Unions have been BRIBED to sppt the plan, big phrma has been BRIBED to sppt the plan, AARP has been BRIBED to sppt the plan. Unions, CONgress, Govt emplee's DONT have to participate.

If I DON'T participate, I'm going to JAIL and have assets SEIZED by the Govt to force me to buy a govt identified prod/svc from a prvt company chosen by the GOVT.

Premiums in prvt mkt are GOING UP perhaps as much as 200% (see Wellpoint and BC/BS studies and CBO scores). Etc, Etc, Etc. READ the bills and the Manager's Amendment (380 pp) and the CBO scoring of at least the Mgr's Amendment (38pp).

The WaPo WAS ONCE a great paper. Now it's a stenographic svc for the O admin. Go to first sources to see for yourself how the public is being LIED TO BY THE MEDIA.

To put it plainly, you accept on blind faith that the estimates provided by politicians are accurate. You know full well that the estimates for Social Security and Medicare were understated by 10x. Additionally, you blithely ignore the massive cost increases proposed for those with private insurance and the incremental burden this will put on states.

Maybe it’s just me but I find it a little disingenuous to accept the premise that Liberal’s intend to REDUCE health care spending by INCREASEING federal funding for, guess what, health care!

The entire agenda of this congress has been to hand out favors to well credentialed liberals and favored parties. Trial lawyer, union bosses, ivory tower intellectuals, insurers, bankers, and thugs from ACORN have all gotten a piece of the action.

The payoffs, waste, fraud and abuse this congress has promoted demonstrate exactly why the federal government should REDUCE its role in the economy. Government’s role must be to establish a fair playing field for all, with rules that are not constantly changed because some cowboy can whip up a populous fervor.

The Liberal agenda seems to be an attempt to tell each American family how much they can spend on health care, and on energy, and how much income the union will allow their family to make.

The why are we spending close to a trillion dollars to do anything? And what about the 10 years following... and the years after that? EVERYBODY's insurance Will BE Changing.

The only 'good feeling' I get out of this article is the knowledge that Ezra Klein is part of the generation that will know what it is like to live in a declining America, one where jobs are decreasing, one where more children live in poverty, one where Nanny America has brought about a helpless america.

Ezra, this is a HUGE deal, because it's what Sen. Tom Harkin called a "starter home" on the way to complete government control over health care. Mandates, extortionate taxes, compulsory coverage---for a country where more than 80% of people are satisfied with their care. NO tort reform ? Exemption of labor unions from the excise tax ? Middle class subsidies ?

The trouble is that at this point, a wide margin of citizens don't want it.

The secrecy, the dirty dealing, the preferential treatment for some, and the strong feeling of a very large part of the public that we are being Ruled rather than Governed have combined in the abysmal general support for this bill.

It would be wise to get the economy "visibly" functional again first, and then try this again - in open, bipartisan, honest fashion.

This is another excellent article by Mr. Klein. At least someone is thinking about health care reform. I think a lot of people are disappointed that the bill has not gone far enough, while at the same time many people see it as going way to far. I find that interesting and the whole debate has been a learning experience for me. It seems to suggest that the USA will be unable to deal successfully with pretty much anything important that comes down the pike, so forget about change and just resign oneself to the continued downward trend of our status quo. To move on will require a totally different strategy that either accepts the governmental and ideological deficits of the country and manipulates within it, or seeks to revolutionize its functioning in an entirely different way. Obviously, if we can't solve something like health care, we are stuck. To a large degree, it seems that the dynamics on this issue has more to do with how representation is proportioned in the Senate than anything else. At this point, we probably should be thinking about Constitutional Reform, rather than health care reform. Without the former, the "will of the people" will continue to be a meaningless slogan. I find it hard to believe that our "founding fathers" could have envisioned giving 2 Senators to Wyoming, with a population of 520,000 people, and 2 Senators to California, with a population of 36,460,000 people. The two nays and the two yeas from the respective states are hardly equal. Nothing against the people from Wyoming but I don't think they could possibly have a clue what would be needed to resolve some of the problems in some of the sections of Jersey City, NJ, for example.

Congress should be more powerful than the Senate. If for no other reason than it would be hard to institutionalize corruption and people could be turned out more easily. Honestly, the whole system needs an overhaul. Between the Senate and the House it doesn't even represent a scientific sampling, given our population size, and if anything has been proven to be a sure bet in our society is that it is easier and cheaper to buy off a smaller number of people than a larger number of people. I try to read all the comments and am constantly struck by the classism, the belief in "market forces." What "force" are these people talking about? The "force" that got us here or the one that will get us out. The Market goes up and the market goes down, we do the hoakie pokie and we all fall down. In this bill, I'm afraid that what we see is the merging of corporation and state, which is more like Fascism, than socialism or capitalism. We should stop and try again, whenever.

A reasonable article, but it unfortunately misleads the reader. What the author calls the cost of health care is actually the price of health care. The cost of care is what it costs the providers to deliver care to us patients. The price of care is what we pay the providers, usually as health insurance premiums, but also as a few of us do, in direct payments to doctors and hospitals. What the author and the Democrats refer to as cost reduction is actually reductions in payments to doctors and hospitals enforced by reductions in insurance premiums. The cost of delivering care is reduced nowhere in the bills before Congress. Forcing price reductions while doing nothing to produce cost reductions makes doctors and hospitals go into the red. This will ruin our health care system. This is why such ideas as tort reform, uniform tax treatment of health care expenses, open competition of insurance companies in all states, and many other ideas suggested by Republicans, should be in the bills. Sweeping these ideas aside has produced bills that are bad for the country and deprived them of bipartisan support. Progressives are blind to the obvious.

Although USA was the leader in quality control, we are behind in Q.C. in many aspects now. Health care is a major one.
We need Continuous Improvement on our health care, education, energy, and so on to control quality. However, quality control is not desirable if it means to trim the gravy train of big insurance or drug companies. They happen to be lobbying on Congress continuously, instead of spending our premiums on improving the quality of our care.

Every other industrial country in the world adopts Universal Health Care and they continuously improve the quality of their health care. The end result is better quality at much lower cost for literally every citizen.

We should not wait for decades to make improvements on our health care. It should be a major topic for every election cycle or annually.

Ezra did a great job using numbers and plots to show what is really happening in health care reform.

Mr Klein I take exception to your comments at the end of the article. Changing the way physicians practice medicine is not something done by detatched policy wonks. The human body is a complex instrument. Treatments vary on an INDIVIDUAL basis irrespective of cost. The cost of diagnostic evaluation specifically has skyrocketed due to not only technological innovation but also due to medicolegal risks associated with the possibility of delay in diagnosis. Maybe if we had some meaningful tort reform these diagnostic costs would decline and allow us to use our innate skills to treat our patients. I assure you this would shave quite a bit more than one percent off of health care costs. You won't hear much of this spoken of in the media of course due to the influence of the trial attorney lobby. Until then I guess I'll have to reassume my assigned role an arrogant, greedy physician ... right ???

The Democrats are on the verge of passing a bill that would insure 31 million people and yes it is going to be expensive. Yes, the truth is that some people’s taxes will be raised in the process. The bill is not perfect by anyone’s standards. Every serious economist says that the only way to begin to get control of the cost of health care is to insure the entire (or nearly) population. Even if there are those of you that don’t think it is a moral obligation to provide access to healthcare the previous sentence ought to provide an economic incentive. Over the long term, providing health care access to the rest of the populace will lower your health insurance premiums, providing an increased incentive for employers to provide higher wages and hire more people as each person be cheaper to employ.
So, to those of you who are active in the Tea Party Movement and anyone else who would like to stop the current health care reform: What do you suggest we do? I live in Oklahoma, I have been reading our conservative leaning editorials in out newspaper, I have been on the conservative blogs and watched and listened to the conservative pundits. I have not heard any comprehensive health care reform ideas from any Tea Party events. I have not read about any comprehensive health care reform in the conservative blogs or the conservative newspapers. I have heard plenty of criticism of the current plan, much of it warranted and helpful. I am not asking for the criticism to be cut short. I would just like to hear the “loyal opposition’s” plan. If there is an alternative, I would like to hear more about it.

No social program has ever cost what the original estimate was. SS and Medicare have exceeded the estimates by billions. The are parts of the bill that are good, but generally it is a far left giveaway to unions and the liberal left.

2014? not if you are unionized. taxpayers will pay for years. Obama needs to reward the unions for paying millions to get him elected. Understood. Sad those of us not unionized will be paying for his election.

OK ... you want a plan ??? How's this for a compromise ... nibble at the edges and dig into the middle. Lower the income threshold for Medicaid (as has been proposed) and lower the age of Medicare eligibilty to 62. Now for the middle. First deregulate the health insurance industry to allow companies to compete across state lines with the large insurers. Instead of having premiums fixed by a monopoly of 4 or 5 publically traded companies you may actually have a decrease in premiums due to more nimble insurers not beholden to Wall Street analysts and shareholders. Secondly provide a 5000 dollar per year tax credit to families for all health insurance costs. That way you provide INCENTIVE to your populace as opposed to COERCION. If you keep yourself healthy you might even makle a little money. Last but not least reasonable tort reform to break the costly cycle of defensive medicine so that we do not exhaust every technological innovation on each patient for little change in outcome. There ... five points, no new government entities and no new draconian taxes. It's not perfect but it's got something for everybody ... and it's a start.

Health bill savings. The CBO is required to believe that doctors under Medicare will see their incomes fall 20% immediately and not receive a raise untl eternity. Does anyone think this will really happen? Be honest. Beware of those numbers trumpeted as potential savings.

This is either a dishonest or an inept piece of journalism. One of the critical goals of health care reform must be to bring the trajectory of health care spending down. Indeed, early on this goal was cited by Obama time and again. The chatter in this article says absolutely nothing regarding how this will be accomplished, and instead takes us over hill, over dale on a discussion of new expenditures relative to overall health care spending.

Journalists and math are more often than not like oil and water, and Ezra Klein is no exception.

Ezra's argument that annualized price tag of 90B is peanuts compared to 2.3T of annual healthcare spending, and therefore it is no big deal is dishonest, where one set of abomination is used for justifying another. Why stop it comparing it to 2.3T? Why not compare it to GDP? That way, even trillions price tag would look trivial. By such logic, one can sell any new entitlement program as small percentage of GDP and make it sound very inconsequential.

The fact is that both 2.3T annual health-care spending and 90B price tags are abominations. Real reforms should seek to downsize them such that even average joe with average income can afford it on their own, out of their own pocket, without needing employers to pay for it, without needing collectivist insurance policies, without needing government welfare or subsidies. Collectivist-payer system has escalated the cost structure and spending - weather collectivist-payer system is administered by profit-motivated private sector or burocracy-infested government sector is hardly a reform. It is more of the same formula that has escalated health-care costs and spending. Real reform would mean moving away from collectivist-payer system to individual-payer system, which forces health-care sector to shape pricing to what average consumers can bear. The boldest reform would be ban all health-care insurance plans and make it illegal for any person to sell or buy health insurance. In stead, this pseudo reform offers just the opposite - it forces everybody to have insurance and criminalizes those who do not need insurance.

The fact that this bill really does not include all that much in terms of really systemic reforms makes me wonder why Republicans have invested so much energy in undermining it.

There is no longer any public option in the bill. Cowardly Centrist Senate Democrats like Lincoln, Lieberman, Landrieu and Nelson saw to that. Why are the Republicans so opposed to trying to ensure coverage for more people, restrain health care spending, and curb insurance company abuses like the individual spending caps and pre-existing condition provisions? I have never understood the Republican opposition here.

In fact the Senate bill is actually quite similar to the moderate Senate Republican Chafee-Durenberger proposal of 1994.

It is clear that with a few exceptions like possibly Snowe, Republicans decided to oppose this bill for political reasons, not for policy reasons. They have done everything they can to incite fear by labeling it "government takeover of health care" which it is clearly not.

The media has largely failed to accurately report and characterize what the bill does and what the policy is. Ezra's work, as well as that of Jonathan Cohn and Johnathan Chait of the New Republic, and of David Herszensohn of the New York Times have tried to focus on the policy more than the politics, but everyone else has resisted reporting on the policy of the bill and instead focused only on the politics.

The national media overall, especially the TV networks, has poorly served the country when it comes to health care reporting.

Exactly -- you are not talking about reform at all, just expansion of the broken model that has driven us where we are today.

"Although the bill solves most of the coverage problem, ..."

That's an absolute myth. Insurance does not equal coverage -- just ask the couple featured at KHN today; they had "good" insurance and ended up with $85 in bills when they assumed that getting permission from their insurer to use an out-of-network pediatric cardiac surgeon for their newborn. There is nothing in the current bill that would change that.

"But changing the growth of the health-care system is a lot harder than just cutting a few dollars here or there. It requires us to change how doctors practice medicine, or how much medicine people buy or how much they need -- or maybe all three"

Ummm, many of us think it also requires a change in how we pay for it. What happened to the idea that coverage from employment? Instead of putting us on a path to actual universal coverage, the current legislation reinforces the "different rules for different groups" problem.

The bottom line Ezra, is that you started off by buying into the idea that the [pick your number] uninsured were "the" problem to be fixed. By framing the problem that way, you and other self-styled reform advocates defined the solution as more insurance and guaranteed that we would not get reform.